Provider Demographics
NPI:1619512514
Name:PETERSON, SHAWNTE LATRYCE (LMT, MPH, CHES)
Entity Type:Individual
Prefix:
First Name:SHAWNTE
Middle Name:LATRYCE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMT, MPH, CHES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4247 WHITE CAP CRST
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-3256
Mailing Address - Country:US
Mailing Address - Phone:678-702-7290
Mailing Address - Fax:
Practice Address - Street 1:4300 PORTSMOUTH BLVD STE 262
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-2138
Practice Address - Country:US
Practice Address - Phone:757-956-5742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-14
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 173C00000X, 174H00000X, 251K00000X
VA0019011750225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No172V00000XOther Service ProvidersCommunity Health Worker
No173C00000XOther Service ProvidersReflexologist
No174H00000XOther Service ProvidersHealth Educator
No251K00000XAgenciesPublic Health or Welfare